Otologic Emergencies Barry E. Hirsch, M.D. Professor, Otolaryngology University of Pittsburgh Medical Center
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Disclosures • This speaker has no commercial relationships to disclose.
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Learning Objectives • Provide a detailed and systematic work‐up for common otologic emergencies including hallmark physical examination findings and interpretation of pertinent laboratory and imaging studies. • Review evidence‐based treatment protocols and guidelines for determining when surgical intervention is warranted. • Determine the appropriate frequency of observation and assessment of treatment response.
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Medical Emergencies • Airway • Bleeding • Circulation
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Otologic Emergencies • • • • •
Trauma Infection Facial paralysis Acute vertigo Sudden hearing loss
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Otologic Emergencies Evaluation • History • Physical Exam – Eye movement (nystagmus) – Facial nerve function – Tympanic membrane – Tuning forks
• Audiometric testing • Imaging Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Otologic Emergencies Trauma
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Otologic Emergencies Trauma to the Pinna • Auricular hematoma / seroma • Laceration
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Otologic Emergencies Auricular Hematoma/Seroma • • • •
Blunt trauma – assault, wrestling Anterior surface Acute pain with tenderness Swelling and fluctuance
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Auricular Hematoma / Seroma Treatment • Drainage – Needle aspiration (18Ga) – Incision • Rubber band, Penrose
• Compression dressing – – – –
Mattress sutures with bolsters Xeroform, cotton/mineral oil Dental roll Silastic sheeting Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Auricular Laceration • Sharp clean edges – Two layer closure
• Skin avulsion – Anterior ‐ 2° healing – Posterior – local flaps
• Human bites – Leave open
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Temporal Bone Trauma
Patel, A: Management of Temporal Bone Trauma CraniomaxillofacTrauma Reconstr. Jun 2010
INCIDENCE • 75% of MVA result in head trauma • 14‐22% of skull fractures involve TB • 31% TB fractures result from MVA – Assaults, falls, motorcycle, pedestrian, GSW
March, A: Temporal Bone Fractures Medscape
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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MECHANISM OF INJURY • 90% blunt trauma • Significant force of 1875 lbs • Associated intracranial injuries ‐ 90%
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
CLASSIFICATION • Relation of fracture to long axis of petrous pyramid: – – – –
Longitudinal Transverse Mixed Olbique
• Otic capsule sparing / disrupting
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
LONGITUDINAL FRACTURES • 80% of TB FXs • Lateral blow • 8‐29% bilateral • • • •
TM disruption Bloody otorrhea CHL 10‐25% VII injury
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LONGITUDINAL FRACTURES
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
TRANSVERSE FRACTURES • 20% of TB FXs • Occipitofrontal blow • • • •
Profound SNHL Vertigo 30‐50% VII injury CSF fistula
TRANSVERSE FRACTURES
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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MIXED FRACTURES • Mixed anatomical & clinical findings
PENETRATING TRAUMA
• Gunshot wounds • More destructive – – – –
36% CNS injury 32% vascular injury 50% VII injury 86% IE/ME injury
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
CLINICAL EVALUATION PRIORITIES • • • •
Airway Hemodynamics Central neurological deficits Cervical spine stability
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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CLINICAL EVALUATION • Eyes: • Ears:
spontaneous nystagmus, racoon eyes Battle’s sign, EAC bleed/otorrhea, TM integrity, hemotympanum
• Nose:
rhinorrhea (halo sign)
• Neuro:
CN VII & VIII (tuning forks/audio)
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
RADIOLOGIC EVALUATION • CT scan: ‐1.0‐1.5mm axial/coronal planes, bone window algorithm ‐ 100% sensitive • MRI scan: ‐ Diagnosis of concomitant CNS injury
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
RADIOLOGIC EVALUATION
labyrinthine fx ossicular discontinuity
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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RADIOLOGIC EVALUATION Pneumolabyrinth
COMPLICATIONS • • • • •
Facial nerve injury CSF leakage & meningitis Hearing loss Vertigo Cholesteatoma
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
FACIAL NERVE INJURY • Majority resolve spontaneously • Determinants for surgical intervention: – Time of onset of paralysis‐ immediate/delayed – Severity of paresis – Mechanism of injury
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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FACIAL NERVE INJURY • Incidence: – 10‐18% OC sparing fx – 38‐50% OC disrupting fx – 45‐50% GSW
• Site: 80‐93% perigeniculate
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
FACIAL NERVE INJURY Immediate vs Delayed Paralysis •
Immediate paralysis = severe nerve trauma/transection = worse prognosis
Natural History of Traumatic Facial Nerve Paralysis (Turner) Paralysis
N
“Good” recovery
Partial recovery with synkinesis
Immediate
19
10 (53%)
6 (32%)
3 (16%)
Delayed
11
9 (82%)
1 (9%)
1 (9%)
No recovery in 1 year
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
FACIAL NERVE INJURY Severity of Paresis • Incomplete paresis usually resolves spontaneously • Intervene surgically if: – 90% or more degeneration by ENoG – No EMG response
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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FACIAL NERVE INJURY Facial Nerve Pathology Discovered During Exploration of Longitudinal Fractures (Fisch/Coker/Lambert & Brackmann)
Facial Nerve Pathology
Frequency(%)
Intraneural edema and/or hematoma
45‐93
Impingement by bony spicule
17‐45
Total nerve transection
0‐26
No pathology found
0‐7
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
FACIAL NERVE INJURY Surgical Management • Approach: – No hearing: translabyrinthine – Hearing: transmastoid & MCF transmastoid & supralabyrinthine • Timing: early repair / grafting • Bony vs epineural decompression
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
FACIAL NERVE INJURY Surgical Management • Bony decompression for neural edema • Epineural decompression for large intraneural hematoma • Remove bony spicules • Primary anastomosis preferred to cable grafting • Epineural neurorrhaphy
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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FACIAL NERVE INJURY Does Sx Intervention Alter Outcome ? Results from Facial Nerve Exploration Following Temporal Bone Trauma Decompression only “Good” results HB I‐II
Nerve Anastomosis “Good” results
Study
N
N HB I‐II
Lambert /Brackmann Kamerer Coker et al.
15 10 (66.6%) Not reported 42 18 (42.8%) 20 0 9 5 (55.5%) 4 0
Totals
66
33 (50.0%)
24 0
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
FACIAL NERVE INJURY In Summary 1. Goal of surgical intervention is to provide most favorable environment for axonal regeneration 2. Explore OC disrupting fractures/GSW when electrical tests indicate poor prognosis 3. Explore OC sparing fractures when CT demonstrates anatomical barrier to nerve regeneration 4. Delayed onset facial paresis usually has good recovery
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
CSF LEAKAGE & MENINGITIS • Incidence of CSF leak 11‐27% – acute – delayed
• Risk of meningitis 12% • Increased risk if: – leak > 7dys (23% vs 3%) – concurrent infection (20% vs 3%)
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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CSF LEAKAGE & MENINGITIS
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
CSF LEAKAGE & MENINGITIS Acute CSF Fistula • Pneumococcus, Staph, Strep, H. influenza • Otorrhea – longitudinal fractures Rhinorrhea – transverse fractures • Role of prophylactic antibiotics controversial – ? Decreased incidence of meningitis – Masking of early infection & antibiotic resistance
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
CSF LEAKAGE & MENINGITIS Acute CSF Fistula • Majority resolve spontaneously in 3‐5 days – Bed rest, head elevation x 5 days – Lumbar drainage if leakage persists after 5 days • Surgical closure of fistulas persisting after 7‐10 days of conservative management
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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CSF LEAKAGE & MENINGITIS Surgical Closure • Approach influenced by: – site of leak – hearing status • OC sparing fractures: MCF, extradural repair OC disrupting fractures: Labyrinthectomy & mastoid obliteration
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
CSF LEAKAGE & MENINGITIS Late Meningitis • May occur years after trauma • Incidence unknown • Incomplete healing of labyrinthine fracture • Labyrinthectomy & obliteration of pneumatized spaces & ET
Respiratory mucosa ingrowth
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
HEARING LOSS • Audiogram as soon as patient is stable – Pure tone thresholds – Tympanogram – Stapedial reflex
• Types of hearing loss: – Sensorineural – Conductive – Mixed
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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HEARING LOSS Sensorineural Hearing Loss • Mechanisms: – Labyrinthine fracture – Labyrinthine concussion or bleed – Noise‐induced HL – PLF – Auditory CNS injury • Majority will not improve significantly with time
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
HEARING LOSS Conductive Hearing Loss 80% resolve with no intervention (6 Weeks) • Hemotympanum: 30‐45 dB CHL • TM perforation : 20 dB CHL • Ossicular dislocation > fracture – Incudostapedial separation most common
• (max CHL of 60 dB if ossicular discontinuity)
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
HEARING LOSS Conductive Hearing Loss Middle Ear Surgical Pathology Found in 31 Patients Following Temporal Bone Trauma (Hough & Stuart) Injury
Incidence (%)
Incudostapedial joint separation Massive dislocation of incus Fracture of stapedial arch Epitympanic fixation of ossicles Fracture of malleus
82.3 57.1 30.0 25.0 11.0
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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HEARING LOSS Conductive HL Management • IS Separation : – Anatomic realignment – Prosthetic reconstruction • Incus Dislocation: – Repositioned autograft – Incus replacement prosthesis
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
HEARING LOSS Conductive HL Management • Stapes Fracture (superstructure): – Footplate fixed: stapedectomy – Footplate mobile: TORP • Malleus Fracture: – Ossicular reconstruction • Epitympanic Fixation – Bony / fibrous: removal – IRP Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
VERTIGO • • • • • •
Postconcussion syndrome Labyrinthine concussion Cupulolithiasis Labyrinthine fracture PLF Delayed endolymphatic hydrops
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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VERTIGO Labyrinthine Concussion • • • • •
Most common cause of posttraumatic vertigo Vertigo with rapid head movement Normal ENG Intact labyrinthine capsule on CT Self‐limited, no treatment
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
VERTIGO Cupulolithiasis • Utricular degeneration releases otoconia into PSC ampulla • Symptoms of BPPV mos / yrs after trauma • Positive Dix‐Hallpike test • Particle repositioning maneuver
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
VERTIGO Labyrinthine Fx • • • • • •
Sudden complete vestibular deficit Debilitating vertigo, nausea & emesis Horizontal nystagmus away from affected ear Absent calorics in affected ear CT positive Vestibular suppressants & physical therapy
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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VERTIGO Perilymphatic Fistula • Explosive / implosive • Fluctuating / progressive SNHL & vertigo, worsened with straining • 58% positive fistula test • Bedrest; exploratory tympanotomy if symptoms persist
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
VERTIGO Dealyed endolymphatic hydrops • Symptoms mos / yrs after trauma • Vertigo, fluctuating HL, tinnitus & aural fullness • Salt restriction, diuretics & vestibular suppressants
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
VERTIGO • Most posttraumatic vertigo is self‐ limited in nature • Litigation may prolong recovery • Surgical intervention for persistent disabling vertigo: – No hearing: labyrinthectomy – Hearing: vestibular nerve section
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Otologic Emergencies Infection
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Otologic Emergencies Infections • Perichondritis • Otitis externa • Otitis media
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Perichondritis • Trauma (piercing) often involved • Involvement over the cartilagenous pinna • Ear lobule often spared • Pseudomonas most common > Staph • Systemic quinolones‐ • Culture specific • Drainage for abscess formation
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Otitis Media • Bullous myringitis • Acute suppurative O.M.
UTMB.edu website
Bullous Myringitis • Acute severe otalgia • Single or multiple fluid filled blisters on the T.M. • Aspirate with 3 or 5 Fr suction • Mycoplasma pneumoniae etiology? – Bacteriology is similar to AOM
• If residual inflammation ‐ topical ofloxacin Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Sudden Hearing Loss Otitis Media • • • • •
Pain Erythematous T.M. Conductive hearing loss by tuning forks Antibiotic treatment Myringotomy
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Acute Otitis Media Microbiology
Frequency
Streptococcus pneumonia Hemophilius influenze Moraxella catarrhalis Streptococcus Group A Staphylococcus aureus
(3x) (2x (x)
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Otitis Media Antibiotics • Ampicillin/Amoxocillin – Clavulonic acid
• Cephalosporins – Cefaclor – Cefuroxime – Cefixime
• Trimethoprin – sulfamethoxazole • Erythromycin ‐ sulfisoxazole Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Otologic Emergencies Facial Paralysis
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Otologic Emergencies Facial Paralysis • • • •
Otitis media Bell’s palsy Herpes Zoster oticus‐ Ramsey Hunt syndrome Temporal bone trauma
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Facial Paralysis Acute Otitis Media More frequent in children More likely in adults with AOM Wide myringotomy is needed Antibiotics and steroids Mastoidectomy not necessary unless coalescence • Surgical decompression not indicated
• • • • •
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Facial Paralysis Bell’s Palsy • • • • • •
Prodrome of post‐auricular pain Rapid onset of paresis/paralysis May see small vesicles palate/mouth Presumed of viral origin (Herpes simplex) No associated hearing loss or dizziness Auricular vesicles are absent
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Bell’s Palsy Treatment • Eye Care – Tear replacement, ointment at night – Moisture chamber or patch
• Prednisone – 60 mg tapered
• Electrical testing ENoG • Close follow‐up
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Debra Munsell, PA‐C Bell’s Palsy Clinical Guidelines Today 5‐6 pm Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Facial Paralysis Herpes Zoster Oticus • • • •
Prodrome of pain Auricular vesicles Rapid onset facial paralysis Hearing loss and/or vertigo often
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Herpes Zoster Oticus Treatment • Eye Care – Tear replacement, ointment at night – Moisture chamber or patch
• Prednisone – 60 mg tapered
• Anti‐virals – Acyclovir, famciclovir, valacyclovir
• Electrical testing ENoG • Poor prognosis compare to Bell’s Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Facial Paralysis Temporal Bone Trauma • More common in transverse fractures • Often there is associated hearing loss • Document onset (immediate/delayed) and degree of paresis/paralysis • CT scan, temporal bone; bone window
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Otologic Emergencies Acute Vertigo
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Vestibular Disorders Anatomic Locations • Labyrinth • Vestibular nerve • Central nervous system
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Acute Vertigo Temporal Bone Trauma • • • • •
Nystagmus, nausea, vomiting Sudden hearing loss Facial paralysis often present CT head, temporal bone, bone window Supportive care
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Acute Vertigo Meniere’s Disease • Sudden onset of vertigo – Lasts 15 minutes to 24 hours
• Unilateral hearing loss – Sound distortion/sensitivity
• Unilateral tinnitus • Aural fullness or pressure
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Meniere’s Disease Treatment • Stabilize nausea and vertigo – Droperidol, compazine, diazepam
• Hydration if needed • Follow‐up for long term treatment
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Acute Vertigo Vestibular Neuronitis • • • • •
Occasionally following URI No hearing loss Nystagmus often present Vertigo lasts days to weeks Can be recurrent history
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Acute Vertigo Treatment • • • • • • •
Quick acting droperidol ‐ Inapsine diazepam ‐ Valium odansetron ‐ Zofran promethazine – Phenergan prochlorperazine – Compazine meclizine ‐ Antivert Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Acute Vertigo Wallenberg (lateral medullary) Syndrome • • • • •
Vertigo, nausea, vomiting, nystagmus Ataxia, falling to side of lesion, unable to stand Ipsilateral Horner’s syndrome Dysphagia – ipsilateral palate, vocal cord paralysis Loss of pain and temperature sensation ipsilateral face, contralateral body
Posterior Inferior Cerebellar Artery Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Otologic Emergencies Sudden Hearing Loss
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Otologic Emergencies Sudden Hearing Loss • • • • •
Cerumen impaction Otitis media Trauma Meniere’s Idiopathic
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Sudden Hearing Loss Cerumen Impaction • T.M. is not visible • Tuning forks – Weber – lateralizes – Rinne – B > A
• Dry removal‐ curette, hooks, suction • Wet removal – irrigation rarely
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Sudden Hearing Loss Trauma • • • • • •
Unilateral or bilateral Vertigo with otic capsule involvement Bloody otorrhea, canal lacerations Hemotympanum Tuning forks – conductive/sensorineural Facial paralysis occasionally
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Sudden Hearing Loss Meniere’s Disease • Sensorineural hearing loss – Low frequency upsloping curve
• Aural fullness • Tinnitus • Vertigo – 15 minutes to 24 hours
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
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Sudden Sensorineural Hearing Loss Idiopathic
• • • •
Viral infection Vascular occlusion Inner ear membrane rupture Autoimmune
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Sudden Sensorineural Hearing Loss Idiopathic • Incidence 5–20 per 100,000 • Loss of at least 30 dB in 3 contiguous frequencies
